Justice, Labor, Research, and Power: The Significance and Implications of Parent-Reported Outcomes in Medical-Legal Partnership

As a legal aid union president in New Haven, laboring within shouting distance of a different large research university, I recall how our membership rolled our eyes when Professors Greiner, Pattanayak, and Hennesy of Harvard published their study providing evidence, through a randomized control trial, that law clinic housing work made no difference for clients.¹ Representing, as I was, “lawyers, secretaries, and paralegals who have dedicated their careers to serving poor clients in crisis,”² the authors’ conclusion generated first shock, then denial, and then an anxious realization that somebody’s job was to research and disseminate such conclusions. In a 2013 United States where there was one legal aid lawyer for every 8,893 people who qualified,³ where federal Legal Services Corporation funding had dropped 40% over ten years in real dollars,⁴ and in an America that spends as much on Halloween costumes for its pets as it does legal aid for the poor,⁵ the inquiry felt like a pile-on. It made no more sense to us than asking if a teacher is “good for students,” a nurse “good for the sick,” or a chef “good for the hungry.”⁶

Lawyering for poor and marginalized people can be done more or less well, but our collective experience is that we make a positive difference in the lives of our clients. We are trained, after all, to know the difference between winning and losing a case, and I have never met a legal aid attorney ignorant of the fact that a single win or loss, no matter how consequential, is insufficient to truly bother the core social, economic, and political dynamics that structure poverty in the US. That’s why many legal aid lawyers prize doing more than just casework. More cynically, it may also explain why Congress’s “bipartisan consensus” for legal aid was built on preventing much of that work from being done, through extremely restrictive funding conditions.⁶

Medical-Legal Partnership, at least as I teach and practice it with law students, includes direct legal services, interdisciplinary training, and policy change, the “three-legged stool of MLP.⁷ Within that, practitioners can find “freedom within structure,” ⁸ creatively and ambitiously using their interdisciplinary skills to improve patient and community health. Because quantitative, scientific research is simply a much more important aspect of professional culture in medicine and health care than in law, it was no surprise to me that our MLP work would be subject to rigorous evaluation when it came to efficacy. I was less prepared, although I shouldn’t have been, for the relentless investigation of MLP efficiency, and particularly whether it brings a return on investment to funders, the question sine qua non in the neoliberal era.⁹ But MLP aims to draw from the $4.5 trillion health care sector, representing 17.3% of domestic GDP, where health care for the poor and marginalized is already regarded by important institutions as a systemic “loss leader,” and is therefore going to beg these questions.¹⁰ Naturally, I sympathize with the sentiment of a brilliant MLP attorney colleague, who I heard tell program evaluators designing questions for a new study, “don’t ask me to tell you the value of putting food on somebody’s table.” But there are a lot of questions worth asking, and in a recent special issue of The Journal of Law, Medicine & Ethics, I urge, along with the other editors, MLPs to “open the books” to researchers concerned with measurement and calculation,¹¹ even as we hone our critiques of that enterprise through careful analysis of the assumptions and hidden politics of various quantitative enterprises.¹²

Medical-Legal Partnership, at least as I teach and practice it with law students, includes direct legal services, interdisciplinary training, and policy change, the “three-legged stool of MLP. Within that, practitioners can find “freedom within structure,” creatively and ambitiously using their interdisciplinary skills to improve patient and community health.

In “Addressing Unmet Social Needs and Social Risks — A Qualitative Interview-Based Assessment of Parent Reported Outcomes and Impact from a Medical Legal Partnership,”¹³ the authors helpfully turned their questioning towards the impact of MLP lawyering on well-known obstacles to access to justice, and towards the reported effects of the intervention on MLP patients and their families, unearthing important testimonies, commentaries, and experiences that evidence, in part, the relative success of this intervention in the eyes of those most closely impacted. As the authors explain, patient and family experience provide first-hand insights into our Medical-Legal Partnership model, and the larger Access to Justice Movement. These testimonies, reproduced in the article’s accompanying tables, invite us to seek more direct patient and family review of our work, and to expand that conversation to include broader, deeper, inquiries into the relationship of our work to the horizon of health justice in the US and elsewhere. I also came away with an appreciation of the excellent lawyering being done at this project on behalf of pediatric clients and their families.

But why does qualitative analysis of family experience matter? MLP practitioners and scholars should pay attention to the issue of how patient families, and in the case of pediatric patients I mean particularly mothers, who are “underestimated,” capable of “fighting hard,” often “underestimated as a parent,” and “ready to drive change at the [school] district,” incorporated legal information into their ongoing advocacy for their children in fights with unsupportive systems. Parents reported that MLP “gives me hope,” and is needed “permanently so that parents know how they can advocate for their kids,” “helped me by getting through to the agency,” and “helped me understand a little bit more and it helped me help other people.”¹⁴ We should follow the authors’ interest in this aspect of MLP work, whether we can effectively leave patients and families, who are already advocates, with more capacity to make change, the definition of power, than they had prior to working with MLP. For many practitioners and teachers like me, who aim to both provide impactful individual service and view MLP as capable of “mobilizing people into power units capable of effecting social change,” the patient testimonies produced in this new research provide us with important new evidence that we can.¹⁵ Future researchers, I hope, will help us evaluate and maintain accountability to those goals.